Diuretics in acute decompensated CHF

How "hard" should we "hit" our patients with Lasix? And does that hurt? Felker et al asked that (sort of) in a NHLBI-funded trial. They gave furosemide to 308 patients hospitalized for ADHF in an IV dose either equivalent to their home dose, or at 2.5 times their home dose, and either at q12-hour intervals or by continuous infusion (i.e., patients assigned to one of four groups in a 2x2 table). No one method was superior on the primary endpoint (a composite global assessment of symptoms). Higher doses of Lasix resulted in more fluid output, without significant renal failure. Continuous drips were not superior to bolus infusion in safety or efficacy.(n=308). NEJM 2011;364:797-805.